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Gastroesophageal reflux disease and obesity. Pathophysiology and implications for treatment
Fernando A. Herbella, Ian Nipomnick, Pietro Tedesco, Marco G. Patti; Department of Surgery, University of California, San Francisco, San Francisco, CA

Background: One third of morbidly obese patients have gastroesophageal reflux disease (GERD). Even though it is accepted that GERD is multifactorial in origin, the pathophysiology of the disease in this group of patients has never been fully investigated. The findings can have important therapeutic implications, both in terms of medical or surgical therapy. Aims: The aims of this study were to compare in patients with GERD and different body mass indexes (BMI): (a) lower esophageal sphincter (LES) profile; (b) esophageal body function; and (c) esophageal acid exposure. Patients and Methods: We reviewed the esophageal manometry and ambulatory pH monitoring studies of 599 consecutive patients with GERD (reflux score>14.7). Patients were divided in 5 groups based on their BMI: group A, BMI<25, 192 patients (32%); group B, BMI 25-29, 227 patients (41%); group C, BMI 30-34, 101 patients (17%); group D, BMI 35-39, 35 patients (6%); and group E, BMI > 40, 44 patients (7%). Patients with previous foregut surgery or named esophageal motility disorders were excluded. Results: Results are shown in the table Conclusions: The results of this study show that: (a) about 1/3 of patients with GERD are obese; (b) in most obese patients with GERD, reflux occurs despite the presence of a normal or hypertensive LES, and normal or hypertensive esophageal peristalsis. These findings raise concern about the wisdom of performing a Nissen fundoplication in obese patients with GERD, and suggest that surgical therapy should be directed toward normalization of the patient’s weight.

 

A

B

C

D

E

Age

52±14

51±13

51±11

47± 2 *

45±9 *

% males

42

55

37

23 *

20 *

LESP (mmHg)

14±7

13±7

16±9

14±9

19±9 *

LESL (cm)

2.4±0.8

2.3±0.8

2.4±0.8

2.3±1.0

2.3±0.9

DEA (mmHg)

89±52 99±53 103±57 * 106±65 124±55 *

99±53

103±57

106±65

124±55 *

PEA (mmHg)

67±36

66±31

69±35

74±37

73±30


LESP: LES pressure . LESL: LES length.
DEA: distal esophageal body amplitude. PEA: proximal esophageal body amplitude. * statistically significant compared to group A (p<0.005)


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